Straight or Gay, Healthcare is a Human Right

One of the most basic of human rights is healthcare. When we talk about documenting appropriately in healthcare, we must keep in mind that documentation is the second step in the process. The first step is the collection of information through subjective discussions with our patients.

We, as providers, must be non-judgmental in communicating with our patients in order to capture the most comprehensive information to provide appropriate, effective, and efficient care. We must allow our patients to be comfortable in communicating their healthcare problems, concerns, and needs.

I have practiced obstetrics and gynecology for a number of years, and therefore have learned to be comfortable in almost any environment – especially regarding discussing sexuality in patients. It is very important for patients to be comfortable and honest with me, but it is also significantly important for me to feel comfortable with my patients, no matter their sexual orientation. Specificity can only be captured through openness to, and with, our patients. For some providers, openness does not have to equal acceptance, but it must equal respectfulness, candor, and honesty.

When documenting (and coding) for transgender individuals, there are some ICD-10 codes, for example: Z87.890, personal history of sex reassignment; F64.0, transsexualism; and F64.1, transvestism. It is becoming more important to document birth sex, or genetic gender, as well as gender identity. Utilization of the sexual assignment codes will help with conflicting data, such as the reality of anatomical gender identity – females cannot have prostate cancer, but males can have breast cancer. Also, birth-sex males are 25 times more likely to develop inguinal hernias than birth-sex females, and females are incapable of suffering testicular torsion. Keep in mind that patients are all just looking for care as human beings, and treatment reflecting as such. Therefore, the most appropriate way to document gender is to capture whether a patient is transgender, and then the anatomical birth sex, as well as the current specific gender identity. This best meets both the needs of the patient and the documentation system, within which we must work. The medical record must be evidence-based, factually based, but inclusive of the sensitivities and preferences of our patient. 

When I was in clinical practice, I had a significant lesbian and bisexual population. Even before patients were “coming out,” distinct, unique needs were self-evident. This guided my thinking, as well as my practice, toward being non-judgmental. One of the points that was very evident was that no matter their sexual orientation, patients just want to be treated and respected as human beings, no more and definitely no less. I must admit that I had challenges initially in providing care for transgender patients. But I soon found out that even though there was nothing I could do for them gynecologically, they were coming to an environment that they hoped would be accepting and safe.

I am sorry to this day that I never at least talked to the first transgender patient who came to my office (I had her sent away by my staff). I turned her away because I felt that there was nothing I could do for her. After that time, I have talked to transgender patients upon presentation to my office, and found that there was just basic medical care that was needed – not gynecological. Such patients usually just wanted to come to an environment where they did not feel judged. This is what we all should be allowed to have in life – no more and definitely no less. 

Facebook
Twitter
LinkedIn

Betty B. Bibbins, MD, BSN, CHC, C-CDI, CPEHR, CPHIT, CPHIMS

Dr. Betty Bibbins is an executive consultant and the founder of DocuComp LLC. DocuComp is dedicated to improving clinical documentation, compliance, and your revenue by helping the healthcare industry effectively communicate quality care.

Related Stories

Leave a Reply

Please log in to your account to comment on this article.

Featured Webcasts

2026 IPPS Masterclass 3: Master MS-DRG Shifts and NTAPs

2026 IPPS Masterclass Day 3: MS-DRG Shifts and NTAPs

This third session in our 2026 IPPS Masterclass will feature a review of FY26 changes to the MS-DRG methodology and new technology add-on payments (NTAPs), presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 14, 2025
2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

2026 IPPS Masterclass Day 2: Master ICD-10-PCS Changes

This second session in our 2026 IPPS Masterclass will feature a review the FY26 changes to ICD-10-PCS codes. This information will be presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 13, 2025
2026 IPPS Masterclass 1: Master ICD-10-CM Changes

2026 IPPS Masterclass Day 1: Master ICD-10-CM Changes

This first session in our 2026 IPPS Masterclass will feature an in-depth explanation of FY26 changes to ICD-10-CM codes and guidelines, CCs/MCCs, and revisions to the MCE, presented by presented by nationally recognized ICD-10 coding expert Christine Geiger, MA, RHIA, CCS, CRC, with bonus insights and analysis from Dr. James Kennedy.

August 12, 2025

Trending News

Featured Webcasts

The Two-Midnight Rule: New Challenges, Proven Strategies

The Two-Midnight Rule: New Challenges, Proven Strategies

RACmonitor is proud to welcome back Dr. Ronald Hirsch, one of his most requested webcasts. In this highly anticipated session, Dr. Hirsch will break down the complex Two Midnight Rule Medicare regulations, translating them into clear, actionable guidance. He’ll walk you through the basics of the rule, offer expert interpretation, and apply the rule to real-world clinical scenarios—so you leave with greater clarity, confidence, and the tools to ensure compliance.

June 19, 2025
Open Door Forum Webcast Series

Open Door Forum Webcast Series

Bring your questions and join the conversation during this open forum series, live every Wednesday at 10 a.m. EST from June 11–July 30. Hosted by Chuck Buck, these fast-paced 30-minute sessions connect you directly with top healthcare experts tackling today’s most urgent compliance and policy issues.

June 11, 2025
Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Open Door Forum: The Changing Face of Addiction: Coding, Compliance & Care

Substance abuse is everywhere. It’s a complicated diagnosis with wide-ranging implications well beyond acute care. The face of addiction continues to change so it’s important to remember not just the addict but the spectrum of extended victims and the other social determinants and legal ramifications. Join John K. Hall, MD, JD, MBA, FCLM, FRCPC, for a critical Q&A on navigating substance abuse in 2025.  Register today and be a part of the conversation!

July 16, 2025

Trending News

Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more

Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!

CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24